Outcomes of dialysis in newborns
Gianni CelsiPediatric Nephrology Unit
Karolinska University Hospital,
Stockholm, Sweden
Causes of ARF in neonates
• Prerenal 75-80%
• Intrinsic 10-15%
• Postrenal 5-10%
hypovolemia, sepsis,
low cardiac output
PUV,PJO
How is the prognosis of pre- and postrenal ARF in
neonates?
Prognosis of ARF
40-60 % survival
Depending on underling disease
Depending on co-morbidity
Reversible
What about ESRD?
Causes of ESRD in neonates
• Prerenal
• Intrinsic
• Postrenal
Causes of intrinsic renal ESRD in
neonates
• Prenatal Agenesis Hypoplasia Dysplasia Cystic diseases Obstruction
• Postnatal DIC, ATN
What is the general consensus for intrinsic ESRD in neonates?
Intrinsic renal ESRD in neonates
• Rare• Extremely poor prognosis
Renal replacement therapy not always recommended. As recently as 1998, only 40% of international pediatric nephrologists would offer dialysis to infants < 1 month (J. Pediatr 1998, 133, 154-65)
How is the prognosis of ESRD in neonates?
Survival after dialysis in neonates with ESRD
9091d-2 mLaakkonen et alNephrol Dial Transplant 2008
53 351 d-1 y Williams et al, Arch Pediatr Adolesc Med 2002
5531<1 mCoulthard et al, Arch Dis Child 2002
7634<3 m Warady et al, Pediatr Nephrol 99
infants with anuria or oliguria had a higher mortality (64%) than did infants with adequate urine output (20%).
80-3621<1 yEllis et al, Adv Perit Dial. 1995
6523<1 yBlowey et al, JPerinatol. 1993
infants whose renal failure was isolated were more likely to undergo successful dialysis
3931<2 mMatthews et al,J Ped Surg1990
Survival %
nAge at start
Outcomes of dialysis initiated during the neonathal period for treatment of ESRD: a NAPRTCS special analysis.
Pediatrics 2007: 468-473; 119
For physicians and parents alike, the decision to initiate long-
term dialysis for a neonate with presumptive ESRD poses a
complex ethical quandary.This dilemma derives,at least in
part, from the paucity of published reports describing the
outcomes of infants who initiate dialysis during the first month
of life.
Neonates were as likely to terminate dialysis during the study
period as were older children. However, the reason for
terminating dialysis differed significantly between the 2 age
groups. Neonates were more likely to terminate because of death,
and they were less likely to terminate because of transplantation.
Death 17/193
Recovery of function 23/193
Neonates with renal dysplasia or obstructive uropathy are at risk for
associated congenital anomalies, either true malformations or
deformations, because of severe oligohydramnios. In such cases,
the presence of significant comorbid conditions may preclude long-
term dialysis as a bridge to renal transplantation, thus excluding
these neonates from the NAPRTCS database.
Aetiology and outcome of acute and chronic renal failure in infants
Nephrol Dial Transplant (2008) 23: 1575–1580
Between 1997 and 2004 all children <1 year of age with
a serum creatinine >100 µmol/l were followed up for up to 6 years.
- 49 infants with ESRD- 21 started dialysis between 5-531 days of age
- 4 neonates were not offered RRT because of parents wish
- mortality: ARPKD 100%
dysplasia 22%
obstraction 6%
Prenatal diagnosis of bilateral isolated fetal hyperechogenic
kidneys. Is it possible to predict long term outcome?
Brit J Obs Gyn 2002
33679Others
71287ADPKD
304520ARPKD
Survival %TOP %n
Congenital renal tract anomalies: outcome and follow-upof 402 cases detected antenatally between 1986 and 2001
Ultrasound Obstet Gynecol 2005
83674Unilateral agenesis,MCDK,
dysplasia
34876Bilateral agenesis,
MCDK, PDCK, dysplasia
Survival %TOP %n
How is the prognosis of ESRD in preterms?
Renal failure, comorbidity and mortality in preterm infants
Wien Klin Wochenschr (2008) 120/5–6: 153–157
02Cong. anomalies
3314Pre/post
Survival %n
16 RF/ 359 <37 GA (4,5%)
Nephrol Dial Transplant (2007) 22: 432–439
Antenatal oligohydramnios of renal origin: long-term outcome
A total of 23 infants (16 males, 7 females) with an antenatal
diagnosis of oligohydramnios were retrospectively studied
- Survival 70%
- 4 children were not offered RRT (GA 34-39)
- only 2 children started dialysis at birth (GA 38-40)
Age at onset of dialysis in preterms with ESRD
02468
1012
1985 1990 1995 2000 2005 2010
Year
Ag
e (
m)
No+/-+37
No-+33
No+/-+35
No-+31
No-+37
KT++36
SurvivalDiuresisOligohydr.GA
Survival of preterms with dialysis onset at birth
What shall we do?
Renal replacement therapy in
neonates/preterms with ESRD
Feasible
Aim: Improve quality of life
Caveat: Avoid damage
Respect autonomy
Be fair